Penis pumps covered by Medicare discontinued by CongressFor 25 years Men suffering from erectile dysfunction could expect Medicare Part B would cover 80% of the cost or allowable set for Medicare beneficiaries to purchase a penis pump.  The primary requirement was that the underlying diagnosis or cause of erectile dysfunction was a covered condition.

 

If you were a man that had a  Medicare supplement plan F or G, or you had a secondary insurance policy without a sexual dysfunction exclusion designed to pay what Medicare would not, then 100% of the cost would likely be covered.  In July of 2015 Congress passed a law that completely discontinued Medicare coverage.

 

Medicare approved ED Pumps

 

The Department of Health and Human Services issued the following statement in 2014:

Section 203 of the Achieving a Better Life Experience (ABLE) Act of 2014 implements changes to treat VES prosthetic devices and related accessories as statutorily noncovered in the same manner that erectile dysfunction drugs are treated in Part D. Effective for claims with dates of service on or after July 1, 2015, DME MACs will deny claims submitted with HCPCS codes L7900 and L7902.

 

Letter of Medical Necessity

 

On July 21, 2014 medical necessity documentation requirements were significantly modified by Medicare. 

When this happened the number of claims paid by Medicare was considerably reduced.  Documentation requirements became burdensome, many physicians struggled to keep up with these requirements and many claims did not qualify for payment. 

The following items became a requirement for a vacuum device or penis pump to be covered by Medicare in July of 2014:

 

  • Hand written notes rather than forms (which were used in the past).
  • Written documentation of other ED treatments attempted and failed, the lack of other attempted treatments became enough reason to reject a claim or request for payment.
  • Untreated hypogonadism or hyperprolactinemia must be ruled out in the patient records.
  • Documentation of a rectal prostate exam in the doctor’s notes 12 months prior to a written prescription.
  • Clear written explanation of the medical necessity of the device should be detailed in the hand-written records.

 

It was recommended that all device suppliers obtain a full record of the beneficiaries’ medical record and if the July 2014 requirements were not met it was the job of the company selling the device to review the records and determine if the physician’s records were sufficient to dispense.

This was all prior to the passing of the ABLE act.  So, for all practical purposes Medicare coverage was significantly reduced in July of 2014, a full year before the treatment was officially terminated.

Prior to July 2014 a prescribing physician was required by Medicare to:

  1. designate by code that the cause of erectile dysfunction was organic (607.84) and not psychogenic (302.72).
  2. Secondly the physician needed to identify by code the underlying cause of erectile dysfunction such as diabetes or hypertension to get claims paid.

Before medical documentation requirements imposed in 2014, a letter of medical necessity for a penis pump was typically issued by a physician when a request or claim was being rejected or denied, for the purpose of appeal.

 

Why did Medicare decide to cover the penis pump?

 

Medicare began covering the penis pump in 1990.  The FDA approved the first vacuum erection system for sale by prescription in 1982 and within several years Medicare beneficiaries became aware that Medicare was paying $ 10,000.00 – $ 15,000.00 for surgical penile implants

In addition, Medicare had billing procedure codes for removing defective implantable components and additional procedure codes for follow up surgeries to maintain surgical penile implants.

At the time surgical Implants for erectile dysfunction were costing the government a lot of money. External penis pumps made a lot of sense for Medicare.

Men began a letter writing campaign in the mid 1980’s to have external vacuum therapy products for erectile dysfunction covered by Medicare.  It didn’t require much common sense for Medicare to decide to begin covering the therapy.

It was inexpensive to pay several hundred dollars for a non-invasive, non-surgical device that was effective in over 90% of men with few side effects compared to the surgical procedures they were covering at the time.

 

Medicare Coverage for Erectile Dysfunction

 

When Medicare covered penis pumps, the principle reason for coverage was related to treatment of the underlying cause of the condition and not sexual activity, even though it is known that sexual activity has health benefits. 

For example, if you are a man with diabetes various supplies that are related to the treatment of diabetes are covered.

Erectile dysfunction is a common side effect of diabetes. Thus, a penis pump was a covered item.

This approach was true for men with a diagnosed primary health condition which is covered by Medicare such as heart disease, prostate cancer and other conditions that impact multiple facets of life and health. 

In the example of diabetics with erectile dysfunction, a vacuum erection system was considered like diabetic shoes as both improve blood flow.

 

Why did Medicare decide to stop coverage of the penis pump?

 

Prior to congress passing the ABLE act which discontinued coverage, Medicare established a statutory prohibition on erectile dysfunction drugs.  Penis pumps were exempted from the statute and remained a covered item.

In 2013 Medicare released findings that Medicare was paying twice as much as the Veterans Administration for penis pumps. This report became national news.  It is not known if negative press coverage played a role in eliminating coverage.  However, it was only 24 months later that congress decided to abolish coverage.